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Reimbursement and Practice Management

MACRA

MACRA outlined a new model for Medicare payment, featuring two tracks. The first is to participate in an Advanced Alternative Payment Model (APM), allowing an automatic boost in Medicare reimbursement by five percent. The second track is the Merit-based Incentive Payment System (MIPS), the pathway for those bound by MACRA, but don’t participate in an Advanced APM. Participants may be eligible for a boost in reimbursement, however, downward payment adjustments are the result of the failure to successfully participate.


After reading this article you will be able to understand today's basics of the Medicare Access to Care and CHIP Reauthorization Act (MACRA) and the tracks eligible clinicians can choose from.

View related pearls


Note: The information is accurate at the time of the writing of this article, however, the government often changes program requirements. Therefore, we suggest consulting current regulations to ensure successful participation.  

The Medicare Access to Care and CHIP Reauthorization Act (MACRA) was passed into law in April 2015. Heralded by organizations representing physicians’ interests, the so-called “DocFix” law eliminated the flawed payment formula that had been causing extreme declines in Medicare reimbursement for more than 10 years. While Congress had issued 17 temporary fixes over the past decade, the law finally brought stability in Medicare reimbursement by replacing the problematic formula with a straight, half-percent increase, year over year. Excited by the prospect of this welcomed change, stakeholders didn’t pay careful attention to the reimbursement structure that the federal government set out for 2019 – until now. 

MACRA outlined a new model for Medicare payment, featuring two tracks. The first is to participate in an Advanced Alternative Payment Model (APM), allowing an automatic boost in Medicare reimbursement by five percent. The second track is the Merit-based Incentive Payment System (MIPS), the pathway for those bound by MACRA, but don’t participate in an Advanced APM. Participants may be eligible for a boost in reimbursement, however, downward payment adjustments are the result of the failure to successfully participate. 

The first track – the Advanced APM – is the obvious desired one, offering the automatic 5% increase in Medicare reimbursement. It is, however, a challenge to find an Advanced APM to join. The Centers for Medicare & Medicaid Service (CMS), the federal agency charged with implementing MACRA, chose a very narrow definition for the model. Therefore, only a handful of Advanced APMs exist, with most only accessible by oncologists, nephrologists and primary care physicians. CMS is in the process of expanding the model, with a new Accountable Care Organization (ACO) Track One+ model available in 2018. 

For all other eligible clinicians, the MIPS pathway will be required. Within MIPS, there are four categories: Quality, Cost, Advancing Care Information (ACI) and Improvement Activities. The latter is the only new reporting requirement, since the other categories are simply a reworking of the existing federal pay-for-performance programs, the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM) and the EHR Incentive Program. Under the new program, the categories will be judged, and each eligible clinician issued a composite performance score (CPS). In 2017, the CPS is determined based on weighting 60% for Quality, 25 percent for ACI, and the residual 15% for Improvement Activities. CMS decided to eliminate the cost category for 2017, so the requirements are limited to the three remaining categories. 

Eligible clinicians include physicians, as well as physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. The program expands to other health care professionals – for example, physical therapists - in coming years. MIPS allows reporting on an individual or group basis. 

While the implementation date according to the law is 2019, CMS is using 2017 as the initial performance year. In 2017, eligible clinicians have four options to participate:

  • Report all required elements for any consecutive 90-day reporting period in 2017, and be eligible for a bonus payment.
  • Report more than one, but not all, required elements for the 90-day period, with eligibility for a small bonus payment.
  • Report just one quality measure, one improvement activity or the base ACI measures, and avoid the downward adjustment.
  • Participate successfully in an Advanced APM. 

To facilitate participation, CMS is providing a significant number of resources, as are vendors, specialty societies and professional associations.

Pearl: Verify Eligibility

In 2017, participation under the new Medicare reimbursement model is required by all eligible clinicians, who will otherwise experience a four percent cut to all Medicare payments in 2019. Eligibility, however, is limited to approximately two-thirds of physicians and advanced practice providers, per the Centers for Medicare & Medicaid Services (CMS). Why? Clinicians who bill less than $30,000 in total Medicare Part B allowed charges or see less than 100 Medicare beneficiaries are not eligible, nor are those who have been enrolled with Medicare for less than a year. Meet any one of these criteria, and you don’t need to worry about the new Medicare program titled the Merit-based Incentive Payment System (MIPS). CMS has posted a lookup tool; searchable by National Provider Identifier (NPI), use this resource to determine your MIPS eligibility.

Pearl: MU Review

Advancing Care Information, one of four categories of MIPS, is the next generation of Meaningful Use. ACI features base measures – four or five depending on which track you'll take based on the year of your certification for your electronic health record (EHR) system, plus a host of options to round out your performance score in this category. All in all, 155 points are on the table, and a perfect score requires only 100. If you’ve reported Meaningful Use in the past, you shouldn't have a hard time complying with ACI, however, it's an opportune time to review the requirements to ensure that you’ll be in the position to report them successfully. While advanced practice providers are considered eligible clinicians under MIPS, these health care professionals need not report ACI in 2017.

Pearl: Dual Tracks

There are two tracks to the Medicare reimbursement model ushered in by the passage of Medicare Access to Care and CHIP Reauthorization Act (MACRA). The pathways are Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Although the implementation date is 2019, the government is using 2017 as the initial performance year. Under MIPS, payment adjustments imposed in 2019 are a positive or negative four percent, followed by five percent in 2020, seven percent in 2021, and nine percent from then on. These adjustments are based on the performance of the eligible clinician two years in arrears, noting that high performers may be eligible for an "x" factor — that is, an even higher bonus than the baseline percentages. Eligible clinicians who move practices won't take the burden of the penalties with them, since MIPS offers each participant a unique NPI/TIN combination. (NPI represents the individual's National Provider Identifier, while the TIN is the practice's Tax Identification Number.)

Pearl: CEHRT Cert

Under the Advancing Care Information (ACI) category, eligible clinicians may use a 2014 Certified Electronic Health Record Technology (CEHRT) in 2017. However, the program requires the use of a 2015 CEHRT in subsequent years, according to current regulations. Note, however, that you could decide to not report for ACI. This would bring down your composite performance score (CPS), however, the "zero" would only impact a percentage of the CPS. In 2017, ACI counts for 25% of your CPS. If you capture the maximum points related to the other categories, you could still be in the running for a bonus payment, in addition to avoiding the downward adjustment. (Because the bonus payments are extracted from the penalties — the losers fund the winners, that is — one cannot predict the exact nature of the bonus.) Because EHRs are not required for the other categories, you certainly don't need an EHR to participate successfully in MIPS.

United States